A federal district court denies the majority of a long-term care insurance company's motion for summary judgment in a case alleging that the insurer improperly denied a claim for benefits. Isler v. Bankers Life and Casualty Company (N.D.Fl., No. 1:10cv178-MP-GRJ, Aug. 13, 2012).
Donna Isler was the beneficiary of a long-term care insurance policy provided by Bankers Life. In late 2009 and early 2010, Ms. Isler submitted claims for expenses that she incurred obtaining personal care services from Comfort Keepers. Bankers Life denied coverage for the services that Ms. Isler received, apparently because Comfort Keepers did not indicate on her Care Plan that she needed assistance with two activities of daily living. (Bankers Life has a pattern of rejecting claims of this nature, as described in a previous ElderLawAnswers article.) After Ms. Isler filed a lawsuit objecting to Bankers Life's denial of benefits, the company moved for summary judgment.
In her objection to the motion, Ms. Isler argued that the long-term care insurance policy did not require Comfort Keepers to use a Plan of Care to certify that she was eligible for long-term care benefits. Ms. Isler claimed that the policy was ambiguous about how certification must take place. Because there was no definition of "certify" in the policy, Ms. Isler posited that there must be a way to obtain certification outside of the use of a Care Plan.
The U.S. District Court for the Northern District of Florida denies the majority of Bankers Life's motion for summary judgment. The court finds that letters that the company sent denying Ms. Isler's claim "seem to support the interpretation that Comfort Keepers only needed to certify: (1) Plaintiff was chronically ill, and (2) the Elimination Period was met. . . Thus, because there is a dispute in the evidence concerning whether these services were deemed necessary and actually performed and certified, summary judgment in favor of the insurer is not appropriate."
For the full text of this decision, click here.
Did you know that the ElderLawAnswers database now contains summaries of more than 1,800 fully searchable elder law decisions dating back to 1993? To search the database, click here.
Subscribe to the Knowledge Bank.
